1124037361 NPI number — RANDOLPH D. MALONEY, M.D., PC

Table of content: (NPI 1124037361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124037361 NPI number — RANDOLPH D. MALONEY, M.D., PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDOLPH D. MALONEY, M.D., PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTH SHORE VASCULAR DIAGNOSTIC LABORATORY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124037361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 HERRICK ST
Provider Second Line Business Mailing Address:
SUITE 110 - PARKHURST MEDICAL BLDG.
Provider Business Mailing Address City Name:
BEVERLY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01915-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-922-5535
Provider Business Mailing Address Fax Number:
978-922-5667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 HERRICK ST
Provider Second Line Business Practice Location Address:
SUITE 110 - PARKHURST MEDICAL BLDG.
Provider Business Practice Location Address City Name:
BEVERLY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01915-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-922-5535
Provider Business Practice Location Address Fax Number:
978-922-5667
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALONEY
Authorized Official First Name:
RANDOLPH
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MEDICAL DIRECTOR PRESIDENT
Authorized Official Telephone Number:
978-922-5535

Provider Taxonomy Codes

  • Taxonomy code: 2471V0105X , with the licence number:  RDMS-RVT , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 293D00000X , with the licence number: 35297 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 021569 . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 801461 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9769706 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33434 . This is a "FALLON HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 950000914 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 606913 . This is a "HARVARD PILGRAM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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